Reem Z Sharaiha1, Amy Tyberg2, Mouen A Khashab3, Nikhil A Kumta2, Kunal Karia2, Jose Nieto4, Uzma D Siddiqui5, Irving Waxman5, Virendra Joshi6, Petros C Benias7, Peter Darwin8, Christopher J DiMaio9, Christopher J Mulder10, Shai Friedland11, David G Forcione12, Divyesh V Sejpal13, Tamas A Gonda14, Frank G Gress14, Monica Gaidhane2, Ann Koons5, Ersilia M DeFilippis2, Sanjay Salgado2, Kristen R Weaver2, John M Poneros14, Amrita Sethi14, Sammy Ho15, Vivek Kumbhari3, Vikesh K Singh3, Alan H Tieu3, Viviana Parra2, Alisa Likhitsup16, Craig Womeldorph10, Brenna Casey12, Sreeni S Jonnalagadda16, Amit P Desai2, David L Carr-Locke7, Michel Kahaleh2, Ali A Siddiqui17. 1. Gastroenterology and Hepatology, Weill Cornell Medical Center, New York, New York. Electronic address: rzs9001@med.cornell.edu. 2. Gastroenterology and Hepatology, Weill Cornell Medical Center, New York, New York. 3. Gastroenterology and Hepatology, Johns Hopkins Medical Institute, Baltimore, Maryland. 4. Department of Gastroenterology and Hepatology, Borland Groover Clinic, Jacksonville, Florida. 5. Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medicine and Biological Sciences, Chicago, Illinois. 6. Gastroenterology and Hepatology, Ochsner Health System, New Orleans, Louisiana. 7. Gastroenterology and Hepatology, Beth Israel Mt Sinai, New York, New York. 8. Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland. 9. Gastroenterology and Hepatology, Mount Sinai Medical Center, New York, New York. 10. Gastroenterology and Hepatology, Brooke Army Medical Center, Fort Sam Houston, Texas. 11. Gastroenterology and Hepatology, Stanford Hospital and Clinics, Palo Alto, California. 12. Gastroenterology and Hepatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. 13. Gastroenterology and Hepatology, North Shore-Long Island Jewish Health System, New York, New York. 14. Gastroenterology and Hepatology, Columbia University Medical Center, New York, New York. 15. Gastroenterology and Hepatology, Montefiore, New York, New York. 16. Gastroenterology and Hepatology, University of Missouri Kansas City, Kansas City, Missouri. 17. Gastroenterology and Hepatology, Jefferson University, Philadelphia, Pennsylvania.
Abstract
BACKGROUND & AIMS: Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with pancreatic walled-off necrosis (WON). Lumen-apposing metal stents (LAMS) have shown success in the management of pancreatic fluid collections. However, there are few data on their specific roles in management of WON. We investigated the efficacy and safety of LAMS in treatment of WON. METHODS: We performed a retrospective multicenter case series of 124 patients with WON who underwent endoscopic transmural drainage by using LAMS at 17 tertiary care centers from January 2014 through May 2015. Patients underwent endoscopic ultrasound-guided cystogastrostomy or cystoenterostomy with placement of an LAMS into the WON collection. At the discretion of the endoscopist, we performed direct endoscopic necrosectomy, irrigation with hydrogen peroxide, and/or nasocystic drain placement. We performed endoscopic retrograde cholangiopancreatography with pancreatic duct stent placement when indicated. Concomitant therapies included direct endoscopic debridement (n = 78), pancreatic duct stent placement for leak (n = 19), hydrogen peroxide-assisted necrosectomy (n = 38), and nasocystic irrigation (n = 22). We collected data for a median time of 4 months (range, 1-34 months) after the LAMS placement. The primary outcomes were rates of technical success (successful placement of the LAMS), clinical success (resolution of WON, on the basis of image analysis, without need for further intervention via surgery or interventional radiology), and adverse events. RESULTS: The median size of the WON was 9.5 cm (range, 4-30 cm). Eight patients had 2 LAMS placed for multiport access, all with technical success (100%). Clinical success was achieved in 107 patients (86.3%) after 3 months of follow-up. Thirteen patients required a percutaneous drain, and 3 required a surgical intervention to manage their WON. The stents remained patent in 94% of patients (117 of 124) and migrated in 5.6% of patients (7 of 124). The median number of endoscopic interventions was 2 (range, 1-9 interventions). CONCLUSIONS: On the basis of a retrospective analysis of 124 patients, endoscopic therapy of WON by using LAMS is safe and effective. Creation of a large and sustained cystogastrostomy or cystoenterostomy tract is effective in the drainage and treatment of WON.
BACKGROUND & AIMS: Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with pancreatic walled-off necrosis (WON). Lumen-apposing metal stents (LAMS) have shown success in the management of pancreatic fluid collections. However, there are few data on their specific roles in management of WON. We investigated the efficacy and safety of LAMS in treatment of WON. METHODS: We performed a retrospective multicenter case series of 124 patients with WON who underwent endoscopic transmural drainage by using LAMS at 17 tertiary care centers from January 2014 through May 2015. Patients underwent endoscopic ultrasound-guided cystogastrostomy or cystoenterostomy with placement of an LAMS into the WON collection. At the discretion of the endoscopist, we performed direct endoscopic necrosectomy, irrigation with hydrogen peroxide, and/or nasocystic drain placement. We performed endoscopic retrograde cholangiopancreatography with pancreatic duct stent placement when indicated. Concomitant therapies included direct endoscopic debridement (n = 78), pancreatic duct stent placement for leak (n = 19), hydrogen peroxide-assisted necrosectomy (n = 38), and nasocystic irrigation (n = 22). We collected data for a median time of 4 months (range, 1-34 months) after the LAMS placement. The primary outcomes were rates of technical success (successful placement of the LAMS), clinical success (resolution of WON, on the basis of image analysis, without need for further intervention via surgery or interventional radiology), and adverse events. RESULTS: The median size of the WON was 9.5 cm (range, 4-30 cm). Eight patients had 2 LAMS placed for multiport access, all with technical success (100%). Clinical success was achieved in 107 patients (86.3%) after 3 months of follow-up. Thirteen patients required a percutaneous drain, and 3 required a surgical intervention to manage their WON. The stents remained patent in 94% of patients (117 of 124) and migrated in 5.6% of patients (7 of 124). The median number of endoscopic interventions was 2 (range, 1-9 interventions). CONCLUSIONS: On the basis of a retrospective analysis of 124 patients, endoscopic therapy of WON by using LAMS is safe and effective. Creation of a large and sustained cystogastrostomy or cystoenterostomy tract is effective in the drainage and treatment of WON.
Authors: Andrea Anderloni; Carlo Fabbri; Jose Nieto; Will Uwe; Markus Dollhopf; José Ramón Aparicio; Manuel Perez-Miranda; Ilaria Tarantino; Alexander Arlt; Frank Vleggaar; Geoffrey Vanbiervliet; Jochen Hampe; Michel Kahaleh; Juan J Vila; Barham K Abu Dayyeh; Andrew C Storm; Alessandro Fugazza; Cecilia Binda; Antoine Charachon; Sergio Sevilla-Ribota; Amy Tyberg; Moran Robert; Sachin Wani; Alessandro Repici; Amrita Sethi; Mouen A Khashab; Rastislav Kunda Journal: Surg Endosc Date: 2020-04-22 Impact factor: 4.584